Annuloplasty band and method

ABSTRACT

An annuloplasty band comprising a sheath, and a generally arcuate stiffening element disposed within the sheath. The stiffening element extends from a first end to a second end, and preferably includes eyelets at its first and second ends adapted to receive sutures to secure the annuloplasty band to a valve annulus. The annuloplasty band preferably has a low profile (e.g., a thickness less than 3 mm). In embodiments intended for mitral valve repair, the eyelets are particularly adapted to receive sutures to secure the annuloplasty band to the antero-lateral trigone and postero-medial trigone. A holder and sizer device useful with the annuloplasty band are also provided.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application claims the benefit of, and incorporates by reference anentirety of, U.S. Application Ser. No. 60/276,174, filed on Mar. 15,2001.

FIELD OF THE INVENTION

This invention relates generally to devices and methods for repair ofheart valves, such as annuloplasty rings and bands, and moreparticularly to an annuloplasty band, annuloplasty band holder,annuloplasty sizer and annuloplasty method.

BACKGROUND OF THE INVENTION

Annuloplasty prostheses, generally categorized as either annuloplastyrings or annuloplasty bands, are employed in conjunction with valvularreconstructive surgery to assist in the correction of heart valvedefects such as stenosis and valvular insufficiency. There are twoatrio-ventricular valves in the heart. That on the left side of theheart known as the mitral valve, and that on the right side known as thetricuspid valve. Anatomically speaking, each valve type forms or definesa valve annulus and valve leaflets. To this end, the mitral andtricuspid valves differ significantly in anatomy. Whereas the annulus ofmitral valve is somewhat “D” shaped, the annulus of the tricuspid valveis more nearly circular.

Both valves can be subjected to or incur damage that requires that thevalve(s) be repaired or replaced. The effects of valvular dysfunctionvary. Mitral regurgitation has more severe physiological consequences tothe patient than tricuspid valve regurgitation, a small amount of whichis tolerated quite well. Many of the defects are associated withdilation of the valve annulus. This dilation not only preventscompetence of the valve but also results in distortion of the normalshape of the valve orifice. Remodeling of the annulus is thereforecentral to most reconstructive procedures on the mitral valve. In thisregard, clinical experience has shown that repair of the valve, whentechnically possible, produces better long-term results as compared tovalve replacement.

Many procedures have been described to correct pathology of the valveleaflets and their associated chordae tendinae and papillary muscles. Inmitral repairs, it is considered important to preserve the normaldistance between the two fibrous trigones. The trigones almost straddlethe anterior leaflet portion of the annulus. Between the left and rightfibrous trigones the mitral annulus is absent (as described by TsakirisA. G. “The physiology of the mitral valve annulus” in The mitral valve—apluridisciplinary approach. ed. Kalmanson D. Publishing Sciences Group,Acton, Ma 1976, pg 21-26). This portion of the mitral valve apparatus isformed by the change of the anterior portion of the base of the aortainto the (so called) sub-aortic curtain, and hence into the anteriorleaflet of the mitral valve. A significant surgical diminution of theinter-trigonal distance could cause left ventricular outflowobstruction. Thus, it is highly desirable to maintain the naturalinter-trigonal distance during and following mitral valve repairsurgery.

Consequently, when a mitral valve is repaired (be it the posterior oranterior leaflet) the result is generally a reduction in the size of theposterior segment of the mitral valve annulus. As a part of the mitralvalve repair, the involved segment of the annulus is diminished (i.e.constricted) so that the leaflets may coapt correctly on closing, or theannulus is stabilized to prevent post-operative dilatation fromoccurring. Either is frequently achieved by the implantation of aprosthetic ring or band in the supra annular position. The purpose ofthe ring or band is to restrict and/or support the annulus to correctand/or prevent valvular insufficiency. However, it is important not toover restrict the annulus or an unacceptable valvular stenosis couldresult. As described above, in mitral valve repair, constriction of themitral annulus should take place only in the area of the posteriorsection of the valve annulus.

Shortening of the posterior portion of the mitral valve annulus may beaccomplished in several ways. Firstly, by implanting a substantiallyinexpansible ring (smaller in size than the annulus). With this type ofdevice the surgeon must accurately choose the size of ring that willjust prevent insufficiency, yet will not cause significant valvularstenosis. Secondly, by using a contractible ring that may be complicatedduring implantation. This type has the disadvantage that the surgeonmust then accurately judge not only the ring size to use, but also howto space the implanting sutures in the ring and the annulus so that,when implanted, insufficiency is minimized, yet there will be nosignificant valvular stenosis. Thirdly, and preferably, by asubstantially inexpansible ring or band that may be contracted only inappropriate segments (and not in the anterior portion). The naturalinter-trigonal distance should be maintained, and the anterior leafletshould not be diminished in circumference.

In tricuspid valve repair, constriction of the annulus usually takesplace in the posterior leaflet segment and in a small portion of theadjacent anterior leaflet. The septal leaflet segment is not usuallyrequired to be shortened.

As described above, both annuloplasty rings and annuloplasty bands areavailable for repair of an atrio-ventricular valve. Examples ofannuloplasty rings are shown in U.S. Pat. Nos. 5,306,296; 5,669,919;5,716,397 and 6,159,240, the teachings of which are incorporated hereinby reference. See, also, Duran C M G, et al. Clinical and HemodynamicPerformance of a Totally Flexible Prosthetic Ring for AtrioventricularValve Reconstruction, (Annals of Thoracic Surgery 1976; 22(5):458-63);and Duran C M G, Repair of Anterior Mitral Leaflet Chordal Rupture ofElongation (The Flip-Over Technique.) (Journal of Cardiac Surgery 1986;1(2):161-66.). A flexible annuloplasty ring has been available under thetrade designation “DURAN™” by Medtronic, Inc., Fridley, Minn., USA. Ingeneral terms, annuloplasty rings completely encompass both the anteriorand posterior portions of the valve annulus. The posterior portion isoften diseased or dilated and not well supported by heart tissue. Theanterior portion, in contrast, is well supported by surrounding hearttissue. Thus, it is possible that the annuloplasty ring may overtlysupport an otherwise healthy anterior portion, potentially leading totissue failure.

Annuloplasty bands, on the other hand, are specifically designed toprimarily encompass only a portion of the valve annulus. For example, amitral valve annuloplasty band is typically configured to encompass onlythe posterior portion of the mitral valve annulus, thus promotingnatural movement of the anterior portion. In addition to facilitatingnatural movement of the healthy portion of the valve annulus,annuloplasty bands can be implanted more quickly than annuloplastyrings, as fewer sutures are required. Examples of annuloplasty bands areshown in U.S. Pat. No. 5,824,066 and PCT International PatentPublication No. WO 00/74603, the teachings of which are incorporatedhereby by reference. While viable, annuloplasty bands present otherconcerns. For example, if the band is only anchored into friable valveannulus tissue, there is some concern that the band may possibly pivotexcessively relative to the valve annulus. Further, the profile (e.g.,thickness) of prior annuloplasty bands may theoretically be sufficientlylarge so as to restrict or disturb blood flow. Thus, a need exists foran annuloplasty band adapted to provide reinforced attachment about thevalve annulus, and a holder and a sizer that facilitate implantationthereof.

SUMMARY OF THE INVENTION

One aspect of the present invention relates to an annuloplasty band thatis readily implanted to repair an atrio-ventricular heart valve, such asthe mitral or tricuspid valve, and which may readily be secured (e.g.,sutured) to the valve annulus tissue, for example to the antero-lateraland/or postero-medial trigones of a mitral valve. Another aspect of thepresent invention relates to methods of implantation of annuloplastybands, for example, by suturing through eyelets adjacent the ends of theband to the valve annulus tissue. This provides an annuloplasty bandthat is anchored into the fibrous tissue of the valve (for example, inone embodiment, the antero-lateral and postero-medial trigones), whichis believed to provide many of the advantages of annuloplasty rings,without sacrificing the advantages of an annuloplasty band. To this end,yet another aspect of the present invention relates to a holder forselectively maintaining the annuloplasty band during the implantprocedure, the holder adapted to facilitate passage of sutures throughthe eyelets. Yet another aspect of the present invention relates to asizer adapted to promote accurate evaluation of the valve annulus viasizer cut-out segments and sizer shape, and thus selection of anoptimally sized annuloplasty band.

In one preferred embodiment, the annuloplasty band of the presentinvention comprises a sheath, and a generally arcuate stiffening elementdisposed within the sheath. The stiffening element extends from a firstend to a second end, and includes eyelets at its first and second endsadapted to receive sutures to secure the annuloplasty band to a valveannulus.

In annuloplasty bands of the present invention intended for mitral valverepair, the stiffening element is preferably configured such that afterimplant, the stiffening element extends from a first end adjacent theantero-lateral trigone past the posterior leaflet to a second endadjacent the postero-medial trigone, and the eyelets are adapted toreceive sutures to secure the annuloplasty band to the antero-lateraltrigone and postero-medial trigone. Alternatively, in annuloplasty bandsof the present invention adapted for tricuspid valve repair, thestiffening element is preferably configured to correspond with thenatural tricuspid valve anatomy.

Preferably, the stiffening element comprises wire having opposite endsbent back onto itself to form the eyelets. The wire is preferablyovermolded with an elastomeric material, such as biocompatiblethermoplastic elastomeric or silicone material. The stiffening elementis preferably radio-opaque.

Preferably, the sheath is fabric marked to indicate eyelet placement.For example, the fabric sheath may be marked to indicate eyeletplacement by a suture of contrasting color to the fabric sheath.

In a second preferred embodiment of the present invention, theannuloplasty band generally comprises a sheath, and a generally arcuatestiffening element disposed within the sheath. The stiffening elementhas rounded ends, and the band has a thickness no greater than about 3mm, preferably no greater than 2.7 mm, and most preferably no greaterthan 2.5 mm. The low profile annuloplasty band offers less restrictionor disturbance to blood flow through the valve. Hence, the minimalcross-section annuloplasty band may reduce stenosis and turbulence, andmay minimize the risk of thrombus formation.

In another preferred embodiment of the invention, a method ofimplantation of an annuloplasty band along the annulus of anatrio-ventricular valve to repair the valve generally comprises thefollowing steps:

(a) Providing an annuloplasty band comprising a sheath and a generallyarcuate stiffening element disposed within the sheath, the stiffeningelement extending from a first end to a second end, the stiffeningelement including eyelets at its first and second ends adapted toreceive sutures to secure the annuloplasty band to a valve annulus;

(b) Positioning the annuloplasty band along the valve annulus toencompass a leaflet of the valve annulus, with the first and second endsof the stiffening element positioned adjacent desired portions of thevalve annulus; and

(c) Suturing the eyelets to the valve annulus.

In one preferred embodiment, the above-described method relates torepair of a mitral valve. In this regard, the eyelets are preferablypositioned adjacent the antero-lateral trigone and the postero-medialtrigone, respectively. The eyelets are then preferably sutured to thevalve annulus at the antero-lateral and postero-medial trigones. In analternative embodiment, the above-described method relates to repair ofa tricuspid valve. To this end, the annuloplasty band is positioned tosurround the anterior, posterior and a portion of the septal leaflets ofthe tricuspid valve. The eyelets are sutured to the respective bases ofthe septal and anterior valve leaflets, adjacent the valve annulus andon either side of the antero-septal commissure to avoid impairment withthe cardiac conduction system of the heart.

In still another preferred embodiment of the invention, a holder isprovided in combination with an annuloplasty band. The annuloplasty bandis mounted on the holder to help position the annuloplasty band relativeto the valve annulus. The holder includes a band-retaining plate formingcut-out areas providing clearance about eyelets formed by the band,thereby promoting placement of sutures through the eyelets.

Yet another aspect of the present invention relates to a sizer forevaluating a size the valve annulus implant site and indicating which ofa number of varying sized annuloplasty bands is best suited for thevalve annulus. In a preferred embodiment, a plurality of differentlysized sizers are provided, each corresponding in size with anannuloplasty band of the present invention. In this regard, each of thesizers preferably includes markings that identify a potential locationof the corresponding annuloplasty band's eyelets were thecorrespondingly sized band selected for implant. Along these same lines,the sizer delineates a distance between desirable points of the valveannulus. With respect to mitral valve repair procedure, the sizeraffords a surgeon the ability to measure an intertrigonal distance andan area of a leaflet of the valve (e.g., anterior leaflet) in order toselect an annuloplasty band that most closely matches those parameters.

BRIEF DESCRIPTION OF THE DRAWINGS

The invention will be further described with reference to the drawingwherein corresponding reference characters indicate corresponding partsthroughout the several views of the drawing, and wherein:

FIG. 1 is a top view of one preferred embodiment annuloplasty band inaccordance with the present invention, with portions peeled away;

FIG. 2 is a cross-sectional view along lines 2-2 of FIG. 1;

FIG. 3 is a top view of a stiffening element employed in theannuloplasty band of FIG. 1;

FIG. 4 is an enlarged view of a portion of FIG. 1 illustrating a markthat is provided to indicate the location of any underlying eyelet onthe annuloplasty band;

FIG. 5 is view similar to FIG. 4 with portions of the fabric sheathbroken away to show the eyelet;

FIG. 6 is a perspective representation of one preferred embodimentstiffening element relative to the X-Y plane and Z direction;

FIG. 7 is a side view of the stiffening element of FIG. 7 in the X-Yplane and Z direction, illustrating a saddle-shaped curve in the Zdirection in accordance with one embodiment of the present invention;

FIG. 8 is an exploded perspective view of an annuloplasty band of FIG. 1in combination with a holder in accordance with one preferred embodimentof the present invention;

FIG. 9 is a perspective view of the combination of FIG. 8, illustratinga handle of the holder being attached to a band-retaining plate;

FIG. 10 is a perspective, exploded view illustrating assembly of anannuloplasty band to a band-retaining plate;

FIG. 11A is a top view of the assembled annuloplasty band/band-retainingplate;

FIG. 11B is a bottom view of the assembly of FIG. 11A;

FIG. 12 is an exploded view of a sizer/handle device in accordance withthe present invention;

FIG. 13 is a top view of a sizer portion of the device of FIG. 12;

FIG. 14 is a perspective view of the sizer device held near a mitralvalve;

FIG. 15 is a perspective view of the combination of FIGS. 8-11,illustrating removal of the identifying tag to be added to the patient'srecords;

FIG. 16 is perspective view of the combination of FIG. 15 held near amitral valve;

FIG. 17 is a perspective view of the combination of FIG. 15 illustratingplacing a suture through the annuloplasty band;

FIG. 18 is a cross section through a portion of FIG. 17 illustratingfurther details of placing a suture through the annuloplasty band;

FIG. 19 is a top view of the mitral valve illustrating details ofplacing sutures into cardiac tissue;

FIG. 20 is a perspective view of the combination of FIG. 15 illustratingbringing the band-retaining plate and annuloplasty band in proximitywith the valve annulus and removing the annuloplasty band from theband-retaining plate;

FIGS. 21 and 22 are enlarged views of a portion of FIG. 19 illustratingcutting a suture holding the annuloplasty band to the band-retainingplate;

FIG. 23 is a perspective view of the combination of FIG. 15,illustrating separating the holder from the annuloplasty band;

FIG. 24 is a top view of the annuloplasty band mounted on the valveannulus of a mitral valve; and

FIG. 25 is a top view of an alternative embodiment annuloplasty band inaccordance with the present invention.

DETAILED DESCRIPTION OF PREFERRED EMBODIMENTS

As illustrated in the drawings, and in particular FIG. 1, a preferredembodiment of the annuloplasty band of the invention is designated inits entirety by the reference numeral 40. The annuloplasty band 40 isparticularly adapted to repair one of the atrio-ventricular valves, suchas the mitral and tricuspid valves. As a point of reference, theannuloplasty band 40 illustrated in FIG. 1 is configured for mitralvalve annulus repair, it being understood that other shapes may beincorporated for other valve annulus anatomies (e.g., tricuspid valveannulus). Thus, the present invention is not limited to mitral valveannuloplasty.

With additional reference to the cross-sectional view of FIG. 2, theannuloplasty band 40 generally includes a stiffening element 42, such asstiffening wire, and a fabric sheath 44 enclosing the stiffening element42. The preferred stiffening wire 42 is preferably overmolded with abiocompatible, biostable, implantable, medical grade elastomericmaterial 45, such as elastomeric thermoplastic polymers (e.g.,polyurethane) or silicone (e.g., liquid silicone rubber (LSR)).Alternatively, the stiffening element 42 can be covered with a tubing45, consisting of biocompatible, biostable, implantable, medical gradeelastomeric material such as elastomeric thermoplastic polymers (e.g.,polyurethane) or silicone elastomeric.

The stiffening element 42 is a generally arcuate and mounted within thesheath 44. As shown in FIG. 3, the stiffening element 42 extends from afirst end 46 to a second end 48, and includes eyelets 50 and 52 at itsfirst and second ends 46 and 48. Preferably, the stiffening element 42is formed of wire 42 having opposite ends 46 and 48 bent back ontoitself to form the eyelets 50 and 52. Most preferably, the wire 42consists of a single length of wire. As used herein, “eyelet” means anopening with substantially closed perimeter but does not require aspecific shape (e.g., an eyelet can be round, square, rectangular,trapezoidal, hexagonal, tear-drop, oval, elliptical or any othersuitable shape, although shapes with lower stress concentration androunded features are generally preferred). In preferred embodiments inwhich the stiffening element 42 is formed of wire, for example, therewill be about 0.5 mm gap along the perimeter of the eyelet 50, 52 due tospring back of the wire after forming the eyelet. Regardless, asillustrated in FIGS. 4 and 5, the eyelets 50 and 52 are adapted toreceive at least one suture 61 to secure the annuloplasty band 40 to avalve annulus (not shown) of a heart valve, such as a mitral valve,tricuspid valve, etc.

Preferred shapes of the stiffening element 42 are described in greaterdetail below. In general terms, however, the stiffening element 42 isshaped to match the native or natural shape of the valve annulus inwhich the annuloplasty band 40 is to be applied. Thus, the stiffeningelement 42 can be generally shaped to mimic the native natural mitralvalve annulus anatomy (i.e., generally symmetrical horseshoe-like shape)for mitral valve annulus repair; can be generally shaped to mimic thenative natural tricuspid valve annulus anatomy (i.e., non-symmetricaloffset curve); etc.

In one preferred embodiment, and with additional reference to FIGS. 16and 24, whereby the annuloplasty band 40 is adapted for repair of amitral valve 55, the stiffening element 42 is configured to generallymatch the natural anatomy of the mitral valve 55. As a point ofreference, the mitral valve 55 anatomy is shown in FIGS. 16 and 24 asincluding a valve annulus 54, an anterior lateral trigone 56, aposterior leaflet 58, a postero-medial trigone 60, an inferiorcommissure 62, and a superior commissure 64. With this in mind, theannuloplasty band 40 is configured such that after implant, thestiffening element 42 extends from the first end 46 adjacent theantero-lateral trigone 56 past the posterior leaflet 58 to the secondend 48 adjacent the postero-medial trigone 60. With this one preferredconstruction, and as described in greater detail below, the eyelets 50and 52 are positioned and adapted to be secured to the value annulus 54at the antero-lateral trigone 56 and postero-medial trigone 60. In onemore preferred embodiment, the eyelets 50 and 52 are sufficiently largeto encompass both trigone and adjacent commissure so that the firsteyelet 50 can be positioned and maintained to encompass the inferiorcommissure 62 at the valve annulus 54, and the second eyelet 52 can bepositioned and maintained to encompass the superior commissure 64 at thevalue annulus 54.

With continued reference to one preferred embodiment in which thestiffening element 42, and thus the annuloplasty band 40, is shaped inaccordance with the natural, native mitral valve anatomy, FIGS. 6 and 7illustrate the stiffening element 42 as preferably being generallyarcuate in an X-Y plane (e.g., C-shaped), and generally saddle-shaped inthe Z direction. This configuration generally conforms with the expectednatural shape of the mitral valve annulus 54. With this one preferredconfiguration, the stiffening element 42 forms a compound curve in theX-Y plane (see, e.g., FIG. 3) including (a) an intermediate portion 66having a first radius of curvature R-1, and (b) opposite end portions 68having a second radius of curvature R-2, with the first radius ofcurvature R-1 being greater than the second radius of curvature R-2.Most preferably, the opposite end portions 68 each include (i) atransition segment 70 extending outwardly from the intermediate portion66, with the transition segment 70 having the second radius of curvatureR-2 in the X-Y plane; and (ii) an end segment 72 extending from thetransition segment 70, the end segment 72 having a third radius ofcurvature R-3 in the X-Y plane. In this one preferred embodiment formitral valve repair, the first radius of curvature R-1 is greater thanthe second radius of curvature R-2, and the second radius of curvatureR-2 is greater than the third radius of curvature R-3. The preferredmagnitude of each radius R-1, R-2 and R-3 will vary within thisconstraint depending on the size of the mitral valve being repaired.Alternatively, the stiffening element 42 can assume other shapesappropriate for mitral valve annulus repair. Even further, thestiffening element 42 can assume an entirely different shape, that mayor may not include a saddle-shape component, that corresponds with thenative tricuspid valve anatomy.

In addition to the above shape characteristics, the stiffening element42 is also preferably radio-opaque so that it may readily be visualizedafter implantation. Metal wire, for example, is radio-opaque. The wireeyelets 50 and 52 provide further definition in radiographic images(e.g., X-ray photographs, CAT-scans, etc.) of the annuloplasty band 40after implantation.

Alternatively, the stiffening element 42 may comprise (e.g., consistessentially of) a molded polymeric element. In this alternativeembodiment, the molded polymeric element preferably includes aradio-opaque filler such as, but not limited to, barium sulfate. Theeyelets 50, 52 could be integrally molded with the rest of thestiffening element. (As used herein, “integrally molded” means molded asa single continuous part as opposed to separate parts mechanicallyfastened, welded, glued or adhered together.) The wire 42 may be formedof any medically acceptable implantable biocompatible metal, such asMP35N alloy, Elgiloy™ Co—Cr—Ni alloy wire (American Gage & MachineCompany, Elgin Ill., USA), Haynes™ alloy (Haynes International, Inc.,Kokomo, Ind., USA), titanium, stainless steel, shape memory materialssuch as NITINOL™, or other similar inert biocompatible metal. Forexample, suitable wire is the wrought cobalt-35 nickel-20 chromium-10molybdenum alloy identified as “MP35N” (available from CarpenterTechnology Corporation, Wyomissing, Pa., USA). See also ASTMSpecification “F562-00 Standard Specification for Wrought Cobalt-35Nickel-20 Chromium-10 Molybdenum Alloy for Surgical ImplantApplications” (American Society For Testing And Materials, WestConshohocken, Pa., USA.)

Returning to FIG. 1, the fabric sheath 44 is preferably marked toindicate placement or location of the eyelets 50, 52 otherwiseencompassed by the sheath 44. For example, the fabric sheath 44 may bemarked to indicate eyelet placement by a suture 74 of contrasting colorto the fabric sheath 44. The suture 74 most preferably forms an “X” inthe fabric overlying the eyelet 50 or 52. Alternatively, the sheath 44may be marked by any biocompatible marking that indicates the positionof the respective eyelet 50 or 52.

Preferably, the fabric sheath 44 comprises a knitted polyester (e.g.,Dacron™) fabric, although woven, nonwoven (e.g., spun-bond, melt-blown,staple fiber matrix, etc.) or braided fabrics are also contemplated, aswell as sheaths formed of harvested biological tissue (e.g., pericardialtissue). The fabric sheath 44 may optionally be provided with any ofvarious biocompatible coatings. Most preferably, a longitudinal seam 76is formed along the fabric sheath 44 and is oriented toward theunderside of annuloplasty band 40 in use (see, e.g., FIG. 11 B) so thatthe seam 76 lies against valve tissue and out of the blood flow pathupon implant.

The stiffening element (e.g., wire or molded element) 42 constitutes apreferred embodiment of generally arcuate stiffening means, mountedwithin the sheath 44, for resiliently stiffening the fabric sheath 44.The eyelets 50 and 52 constitute one preferred embodiment of eyeletmeans, at the first and second ends of the stiffening means, forreceiving sutures to secure the annuloplasty band 40 to the valvetissue. A preferred embodiment of the indicating means for indicatingwhere to place a suture so that the suture goes through the eyelets isthe suture of contrasting color to the fabric sheath sewn into thefabric sheath. Two preferred embodiments of the means for providingradio-opaque contrast include (1) forming the stiffening element 42 ofmetal wire, or (2) providing a radio-opaque filler in a molded polymericstiffening element. Regardless, construction of the annuloplasty band 40preferably provides a low profile attribute. More particularly, theannuloplasty band 40 preferably has a maximum cross-sectional thicknessof no greater than about 3 mm, more preferably no greater than about 2.7mm, most preferably no greater than about 2.5 mm.

A preferred embodiment of a holder for use with the annuloplasty band 40is illustrated in FIG. 8, and designated in its entirety by thereference numeral 100. The holder 100 comprises an elongate handle 102and a band-retaining plate 104 selectively mounted on the handle 102.The band-retaining plate 104 of the holder 100 is adapted to retain theannuloplasty band 40 during implantation of the annuloplasty band 40.Thus, in accordance with the one embodiment illustrated in the Figuresin which the annuloplasty band 40 is shaped for mitral valve repair, thegeneral perimeter shape of the band-retaining plate 104 correspondsgenerally with a shape of the mitral valve annulus (an example of whichis designated at 54 in FIG. 16). Alternatively, of course, a perimetershape of the band-retaining plate 104 can vary from that shown, and caninstead corresponding generally with a shape of an alternativelyconfigured annuloplasty band 40 (e.g., a tricuspid valve annuloplastyband). Regardless, the band-retaining plate 104 includes cut-out areas106 adapted to overlap the eyelets 50, of the annuloplasty band 40otherwise secured to the plate 104 to guide the placement of implantingsutures through the eyelet 50, 52, as described below. Most preferably,the band-retaining plate 104 is formed of transparent biocompatiblethermoplastic or synthetic resin material, such as polycarbonate orpolysulfone.

The handle 102 may be of metal, such as an anodized aluminum alloy orstainless steel, or a suitable thermoplastic, thermoset or syntheticresin material. An outer surface of the handle 102 may be knurled toprovide a non-slip finish.

The handle 102 of the holder 100 may be, for example, designed for asnap-fit engagement in the band-retaining plate 104 as illustrated inFIG. 9. Most preferably, the snap-fit engagement is provided by aplurality (e.g., two) of cantilever spring fingers 103 that are receivedin a slot 105 in the band-retaining plate 104. This snap-fit mechanismallows the handle 102 to be attached to the band-retaining plate 104 bythe surgical staff. Alternatively, any suitable temporary or permanentmeans for attaching the handle 102 and band-retaining plate 104 may beemployed, such as, without limitation, threaded means, bayonet-mountingmeans, interference fit, detent lock, welding, adhesive, insert moldingor integrally molding the handle and band-retaining plate.

The annuloplasty band 40 is mounted on the holder 100 to maintain theannuloplasty band 40. Preferably, the annuloplasty band 40 is mountedonto band-retaining plate 104 of the holder 100 at time of manufacture,and the assembly (or combination) is provided as a sterile unit. In onepreferred embodiment, and as illustrated in FIG. 10, the band-retainingplate 104 is adapted to receive a drawstring or suture 108 that isotherwise employed to secure the annuloplasty band 40 to theband-retaining plate 104. More particularly, the band-retaining plate104 forms a plurality of spaced passage pairs 110 a-110 f. Each passagepair 110 a-110 f includes two holes 112 (best illustrated in FIG. 10 forthe passage pair 110 b) extending transversely through theband-retaining plate 104. Each of the holes 112 is adapted to allowpassage of the drawstring suture 108. Further, the holes 112 comprisingany one of the passage pairs 110 a-110 f are separated by a section ofthe band-retaining plate 104. That is to say, each of the passage pairs110 a-110 f includes two distinct holes 112, and is not a continuousslot. With this configuration, the drawstring suture 108 can be threadedaround, and thus engaged by, the band retaining plate 104 as shown. Inone preferred embodiment, the passage pairs 110 b and 110 e furtherinclude two fingers 114 projecting from an upper surface 116 of theband-retaining plate 104. The fingers 114 are positioned between therespective holes 112, and are spaced from one another to define a slot118. Further, each of the fingers 114 forms a channel 120 for receivingthe drawstring suture 108. With this configuration, and as described ingreater detail below, the fingers 114 raise the drawstring suture 108away from the upper surface 116, and provide a space (i.e., the slot118) for severing the drawstring suture 108.

With the above-preferred embodiment in mind, the annuloplasty band 40 issecured to the band-retaining plate 104 by threading the drawstringsuture 108 through the passage pairs 110 a-110 f and the annuloplastyband 104 as shown in FIG. 10. Preferably, a single drawstring suture 108is extended from the first passage pair 110 a (and forming a knot 122 a)downwardly and sewn to the annuloplasty band 40; upwardly from theannuloplasty band 40 to the second passage pair 110 b and around therespective fingers 114; downwardly from the second passage pair 110 band sewn to the annuloplasty band 40; upwardly from the annuloplastyband 40 to the third passage pair 110 c; around the third passage pair110 c, and below the band-retaining plate 104; upwardly to the fourthpassage pair 110 d and wrapped around the fourth passage pair 110 d;downwardly from the fourth passage pair 110 d and sewn to theannuloplasty band 40; upwardly from the annuloplasty band 40 to thefifth passage pair 110 e and around the respective fingers; downwardlyfrom the fifth passage pair 110 e and sewn to the annuloplasty band 40;upwardly from the annuloplasty band 40 and around the sixth passage pair110 d; finally terminating in a knot 122 b. Notably, extension of thedrawstring 108 between the third and fourth passage pairs 110 c, 110 d(and below the band-retaining plate 104) is preferably sufficient toform a loop 124 that is defined by a knot 126. The loop 124 cansubsequently be severed from a remainder of the drawstring suture 108.This preferred configuration assists in tightening the annuloplasty band40 to the band-retaining plate 104. The drawstring suture 108 ispreferably tied to the band-retaining plate 104 in such a manner thatfollowing severing (via the slots 118 formed by the respective fingers114), each severed length of the suture 108 remains connected to theband-retaining plate 104. Notably, directional terminology, such as“upper,” “upwardly,” “downwardly,” “below,” etc., are used for purposesof illustration and with reference to the orientation of FIG. 10. Theannuloplasty band 40 and/or the band-retaining plate 104 can bepositioned at a wide variety of other orientations, such that thedirectional terminology is in no way limiting.

The above-described mounting technique is but one available techniquefor securing the annuloplasty band 40 to the band-retaining plate 104.Preferably, however the various points at which the drawstring suture108 is sewn to the annuloplasty band 40 are discrete and are spaced fromone another. Final assembly of the annuloplasty band 40 to theband-retaining plate 104 is illustrated in FIGS. 11A and 11B. Asdepicted by the top view of FIG. 11A, the cut-out 106 provide clearanceabout the eyelets 50, 52 (hidden in FIG. 11A, but readily identified bythe markings 74 on the sheath 44). Further, the drawstring suture 108 iseasily severed via the slots 118 provided by the fingers 114. Withrespect to the bottom view of FIG. 11B, the annuloplasty band 40 iseffectively mounted to a bottom surface 128 of the band-retaining plate104. In one preferred embodiment, the bottom surface 128 further formsspaced tabs 130, 132, and 134 that serve to generally support a shape ofthe annuloplasty band 40 upon final assembly to the band-retaining plate104. The tabs 130-134 preferably do not form grooves or other side wallcurvatures for receiving the annuloplasty band 40, and preferably do notfollow a circumferential profile of the annuloplasty band 40. Instead,the tabs 130-134 preferably extend in a perpendicular fashion relativeto a plane of the bottom surface 128 and are tangent to the annuloplastyband 40 profile at three points, thereby promoting ease of manufactureof the band-retaining plate 104.

As previously described, alternative configurations/techniques can beemployed for selectively mounting the annuloplasty band 40 to theband-retaining plate 104. To this end, the band-retaining plate 104 canbe configured to maintain the annuloplasty band 40 in a manner that doesnot require the drawstring suture 108. For example, in one alternativeembodiment, the tabs 130-134 are modified to each form a rib (orradially outward projection) opposite the bottom surface 128. Taken incombination, these ribs define a radius of curvature that is slightlygreater than that defined by the annuloplasty band 40. With thisconfiguration, assembly of the annuloplasty band 40 would entail firstexpanding the annuloplasty band 40 (i.e., forcing the ends 46, 48 awayfrom one another) so that the annuloplasty band 40 could be placed overthe ribs. Once properly positioned, the expansion force on theannuloplasty band 40 is released, allowing the annuloplasty band 40 tocontact the tabs 130-134 such that the annuloplasty band 40 is retainedby the tabs 130-134 between the ribs and the bottom surface 128.Following implant to a valve annulus, the annuloplasty band 40 isreleased from the band-retaining plate 104 by simply pulling theband-retaining plate 104 away from the annuloplasty band 40 viamaneuvering.

An additional component useful as part of an implantation procedure forthe annuloplasty band 40 is a sizer device 150 shown in FIG. 12. Thedevice 150 includes a handle 152 and a sizer 154. The handle 150 ispreferably similar, more preferably identical, with the handle 102 (FIG.9) associated with the holder 100 (FIG. 9) previously described. Inother words, the handle 102 used with the holder 100 is preferably alsoused with the sizer device 150, although a different handle can also beemployed.

Regardless, the sizer 154 is preferably configured to be selectivelyassembled to the handle 152, and, with additional reference to FIG. 13,provides a perimeter 156 corresponding generally with a shape of theannuloplasty band 40 (FIG. 1). As such, the perimeter 156 defines ashape corresponding generally with the valve annulus to be repaired(e.g., mitral valve, tricuspid valve, etc.). In the one preferredembodiment, the sizer 154 is configured for evaluating a mitral valve,it being understood that a tricuspid valve sizer in accordance with thepresent invention will define a perimeter corresponding with a naturalshape of a tricuspid valve annulus (not shown).

With respect to the one preferred mitral valve sizer 154, the perimeter156 includes a leading segment 158, a trailing segment 160, and opposingcut-out segments 162. The leading segment 158 extends between theopposing cut-out segments 162, and is preferably curved, mimicking thenatural shape of the mitral valve annulus anatomy. The opposing cut-outsegments 162 are located at approximate positions (relative to theleading segment 158) of the naturally occurring antero-lateral trigoneand the postero-medial trigone, respectively. Thus, and as described ingreater detail below, when placed next to a valve annulus requiringrepair (e.g., mitral valve, tricuspid valve, etc.), the sizer 154, andin particular, the opposing cut-out segment 162, afford a surgeon theability to relatively accurately estimate an intertrigonal distance andrelated leaflet area. To this end, the sizer 154 preferably furtherincludes indicia 164 that highlights a location of the opposing cut-outsegment 162 to the surgeon during use. In another preferred embodimentin which the sizer 154 is configured to evaluate a tricuspid valve, theleading segment 158 will be generally shaped in accordance with a shapeof a natural tricuspid valve annulus in a region of at least theposterior tricuspid valve leaflet. Further, the opposing cut-outsegments 162 would be positioned (relative to the leading segment 158)at the approximate locations of the septal and anterior tricuspid valveleaflets (relative to the naturally occurring tricuspid valve annulus).

Regardless of whether the sizer 154 is configured for mitral ortricuspid valve evaluation, a plurality of differently sized, butsimilarly shaped, sizers are preferably provided. Each of thedifferently sized sizers 154 would preferably correspond with anavailable annuloplasty band 40 (FIG. 1). During use, then, the surgeonwould evaluate the valve annulus to be repaired with several of thedifferently sized sizers 154 (on an individual basis). Once the sizer154 most closely corresponding with the valve anatomy is identified, theannuloplasty band 40 corresponding with that sizer would then beselected for implant.

Operation

The annuloplasty band 40, holder 100, and sizer assembly 150 of thepresent invention may be employed in the repair of various heart valves,particularly the atrio-ventricular valves. One particularly advantageousapplication of the annuloplasty band 40 is for repair of the mitralvalve. Regardless of the exact type of valve being repaired, however,the general method of use is the same. For ease of illustration, thefollowing example (including illustrations) is specific to repair of amitral valve. It should be understood, however, that a tricuspid valvecan similarly be repaired via an annuloplasty band 40 of the presentinvention shaped to generally match the native, natural tricuspid valveanatomy.

Beginning with FIG. 14, the mitral valve 55 is accessed using knownsurgical techniques. The sizer device 150 is then directed toward thevalve annulus 54. In particular, the sizer 154 is then directed towardthe valve annulus 54, with the opposing cut-out segments 162 positionedas close as possible the antero-lateral trigone 56 and thepostero-medial trigone 60, respectively. Once positioned, the surgeoncan evaluate an intertrigonal distance and an area of the anteriorleaflet (referenced generally at 170). Based upon this evaluation, thesurgeon can select an appropriately-sized annuloplasty band 40 (FIG. 1).Alternatively, or in addition, where the sizer 154 utilized does notclosely match the value annulus 54, a second, differently sized sizer(not shown) can subsequently be used to again evaluate the valve annulus54.

With the desired annuloplasty band size in mind, the selectedannuloplasty band 40 is then assembled to the holder 100, as shown inFIG. 15. In a preferred embodiment, the annuloplasty band 40 is providedto the surgeon pre-assembled to the band-retaining plate 104, aspreviously described. With this embodiment, the handle 102 is thenattached to the band-retaining plate 104 by the surgical staff. Wherenecessary, a thread 180 otherwise connecting an identification tag 182to the annuloplasty band 40 may be severed so that the annuloplasty band40 is ready for implant.

The annuloplasty band 40 is then directed to the implant site viamaneuvering of the handle 102, as shown in FIG. 16. With respect to theone exemplary embodiment in which the annuloplasty band 40 is employedto repair the mitral valve 55, the annuloplasty band 40 is guided towardthe valve annulus 54 and oriented to surround, more preferably centeredrelative to, the posterior leaflet 58. The cut-out areas 106 of theband-retaining plate 104 (and thus the eyelets 50, 52 (FIG. 1)) areoriented to be adjacent the antero-lateral trigone 56 and thepostero-medial trigone 60, respectively. Notably, the band-retainingplate 104/annuloplasty band 40 are slightly spaced from the valveannulus 54 a sufficient distance to allow suturing of the annuloplastyband 40 to the valve annulus 54.

With reference to FIGS. 17-19, the annuloplasty band 40 is connected tothe valve annulus 54 with implanting sutures 61. The implanting sutures61 are spaced along a relevant portion of the valve annulus 54 (as isshown in FIG. 19), and pass through the sheath 44 (as best shown in FIG.18). Regardless of an exact spacing, respective ones of the implantingsutures 61 are stitched through the eyelets 50, 52 as best shown by theenlarged view of FIG. 5. To this end, the markings 74 (FIG. 4) visuallyindicate eyelet location to the surgeon, and the cut-out areas 106provide sufficient clearance for passage of the sutures 61. Theimplanting sutures 61 otherwise passed through the eyelets 50, 52 aresecured to tissue of the valve annulus 54. In one preferred embodiment,the implanting suture(s) 61 associated with the eyelet 50 are sewn tothe antero-lateral trigone 56, whereas the implanting suture(s) 61associated with the eyelet 52 are sewn to the postero-medial trigone 60.

At this point, the implanting sutures 61 extend between the annuloplastyband 40 and the valve annulus 54 as a “suture bundle.” Using the handle102, the annuloplasty band 40 is pushed down the suture bundle whilesimultaneously tensioning the implanting sutures 61 so that theannuloplasty band 40 lies close to the valve annulus 54. Thisrelationship is shown in FIG. 20. The drawstring sutures 108 connectedto the band-retaining plate 104 are cut at the passage pairs 110 b, 110e (FIGS. 21, 22), releasing the drawstrings suture 108, and the holder100 is removed (see, e.g., FIG. 23). The implanting sutures 61 are thentightened and tied as shown in FIG. 24.

Upon completion of the implantation procedure, the annuloplasty band 40is fastened to the valve annulus 54 by the implanting sutures 61. Inthis regard, the opposing ends of the annuloplasty band 40 are securelyconnected to the valve annulus 54 via the eyelets 50, 52 (FIG. 3). In amore preferred embodiment, the eyelets 50, 52 are sutured to theantero-lateral and postero-medial trigones 56, 60, respectively, therebyproviding a reinforced connection that greatly minimizes the possibilityof undesirable movement or pivoting of the annuloplasty band 40 relativeto the annulus valve 54 during subsequent cardiac cycling.

Though not illustrated, implantation of an appropriately shapedannuloplasty band 40 to a tricuspid valve annulus entails a procedurehighly similar to that described above. The annuloplasty band 40 isinitially presented to the tricuspid valve while connected to theband-retaining plate (a mitral version of which is shown at 104 in FIG.9), and then sutured to the tricuspid valve annulus tissue. Once again,sutures 61 are passed through the eyelets 50, 52 (FIG. 3) and sewn tothe tricuspid valve tissue to ensure a rigid connection. In onepreferred embodiment, the annuloplasty band 40 shaped for tricuspidvalve repair is oriented such that it surrounds the anterior, theposterior and a portion of the septal tricuspid valve leaflets, with theeyelets 50, 52 positioned adjacent to, and sutured to, the bases of theseptal and anterior tricuspid valve leaflets on either side of theantero-septal commissure. With this one preferred implant positioning,the annuloplasty band 40 avoids impairment of the cardiac conductionsystem of the patient's heart.

Regardless of the valve being repaired, the annuloplasty band 40 ispreferably had a low profile (e.g., maximum cross-sectional thickness nogreater than about 3 mm, more preferably no greater than about 2.7 mm,most preferably no greater than about 2.5 mm). With this preferred lowprofile, the annuloplasty band 40 has surprisingly been found to reducethe potential for stenosis and turbulence within the valve, as well asonset of thrombus by minimizing the restriction or disturbance of bloodflow through the valve.

As various changes could be made in the above constructions and methodswithout departing from the scope of the invention as defined in theclaims, it is intended that all matter contained in the description orshown in the accompanying drawings be interpreted as illustrative andnot in a limiting sense. For example, while the annuloplasty band 40 hasbeen preferably illustrated as being an incomplete ring, a continuousstructure can instead be provided. For example, FIG. 25 depicts analternative embodiment annuloplasty band 200 including the stiffeningelement 42 (shown partially in FIG. 25) disposed within a fabric sheath202. The stiffening element 42 is identical to that previously described(e.g., FIG. 1), and forms the eyelets 50, 52 (FIG. 3). The fabric sheath202 is constructed of a similar material to that previously described.However, the sheath 202 extends beyond the eyelets 50, 52, forming acontinuous ring. The additional sheath 202 material 204 is available foranchoring to the valve annulus (e.g., for mitral valve repair, theadditional material 204 can be anchored to the anterior portion of themitral valve annulus). With this alternative embodiment, theannuloplasty band 200 provides a high degree of flexibility at one sideof the valve annulus (e.g., the anterior portion for a mitral valveapplication) via the additional sheath material 204 (i.e., without thestiffening element 42), and semi-flexibility at the other side (e.g.,the posterior portion for a mitral valve application) via the stiffeningelement 42).

1. A method of implanting an annuloplasty band for repairing anatrio-ventricular valve defining a valve annulus, the method comprising:providing an annuloplasty band including a sheath and a generallyarcuate stiffening element disposed within the sheath, the stiffeningelement extending from a first end to a second end and defining acompound curve shape between the first and second ends so as to mimic atleast a portion of a natural valve annulus, each end forming an eyeletadapted to receive a suture; positioning the annuloplasty band along atleast a portion of the valve annulus; and suturing the respectiveeyelets to tissue of the valve annulus and further suturing theannuloplasty band between the first and second ends thereof to tissue ofthe valve annulus for shaping the valve annulus based upon the shape ofthe stiffening element.
 2. The method of claim 1, wherein theatrio-ventricular valve is a mitral valve defining an antero-lateraltrigone and a postero-medial trigone, and further wherein suturing theeyelets includes suturing the eyelet of the first end to theantero-lateral trigone and suturing the eyelet of the second end to thepostero-medial trigone.
 3. The method of claim 1, wherein theatrio-ventricular valve is a tricuspid valve defining an anteriorleaflet and a septal leaflet, each of the leaflets forming a baserelative to the valve annulus, and further wherein suturing the eyeletsincludes suturing the eyelet of the first end to the base of theanterior leaflet adjacent the valve annulus and suturing the eyelet ofthe second end to the base of the septal leaflet adjacent the valveannulus.
 4. The method of claim 1, wherein providing an annuloplastyband includes forming markings on the sheath indicative of locations ofthe eyelets, and further wherein suturing the eyelets include passingsutures through the respective markings.
 5. A method of implanting anannuloplasty ring for repairing a mitral valve defining a valve annulushaving a posterior annulus portion and an anterior annulus portion, themethod comprising: providing an annuloplasty ring comprising a polyestersheath, a generally arcuate, non-planar stiffening element disposedwithin the polyester sheath, the stiffening element comprising titaniumand having a compound curve shape along at least a posterior portionthereof that is adapted to extend along the posterior annulus portion ofthe mitral valve annulus, wherein the non-planar stiffening elementcomprises a saddle shape to mimic a natural mitral valve annulus;positioning the annuloplasty ring along the valve annulus; and suturingthe ring to tissue of the valve annulus for shaping the valve annulusbased upon the saddle shape of the stiffening element.
 6. A methodaccording to claim 5 wherein the annuloplasty ring comprises first andsecond eyelets, the mitral valve defines an antero-lateral trigone and apostero-medial trigone, and further wherein suturing the ring includessuturing the first eyelet to the antero-lateral trigone and suturing thesecond eyelet to the postero-medial trigone.
 7. The method of claim 6,wherein providing an annuloplasty ring includes forming markings on thesheath indicative of locations of the eyelets, and further whereinsuturing the eyelets includes passing sutures through the respectivemarkings.
 8. A method of implanting an annuloplasty ring for repairing amitral valve defining a valve annulus having a posterior annulus portionand an anterior annulus portion, the method comprising: providing anannuloplasty ring comprising a polyester sheath, a generally arcuate,non-planar stiffening element disposed within the polyester sheath, thestiffening element comprising titanium and having a compound curve shapealong at least a posterior portion thereof that is adapted to extendalong the posterior annulus portion of the mitral valve annulus, whereinthe ring comprises a continuous saddle shape; associating a holder withthe annuloplasty ring; positioning the annuloplasty ring and associatedholder along the valve annulus; and suturing the ring to tissue of thevalve annulus for shaping the valve annulus based upon the saddle shapeof the stiffening element; and disassociating the holder from the ring.9. A method according claim 8, wherein the annuloplasty ring comprisesfirst and second eyelets, the mitral valve defines an antero-lateraltrigone and a postero-medial trigone, and further wherein suturing thering includes suturing the first eyelet to the antero-lateral trigoneand suturing the second eyelet to the postero-medial trigone.
 10. Themethod of claim 9, wherein providing an annuloplasty ring includesforming markings on the sheath indicative of locations of the eyelets,and further wherein suturing the eyelets includes passing suturesthrough the respective markings.
 11. The method of claim 8, whereinassociating a holder with the annuloplasty ring comprises suturing thering to the holder.
 12. The method of claim 11 wherein disassociatingthe holder from the ring comprises cutting the suture that sutures thering to the holder.
 13. The method of claim 8 wherein providing a ringcomprises providing a metal stiffening element that has a first radiusof curvature in an X-Y plane and a second radius of curvature in the X-Yplane, the internal metal stiffening element having a saddle shape in aZ plane.